Hyperosmolar hyperglycemic state differential diagnosis: Difference between revisions

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__NOTOC__
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{{Hyperosmolar hyperglycemic state}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Hyperosmolar_hyperglycemic_state]]
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{HS}}


==Overview==
==Overview==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
The hyperosmolar hyperglycemic state must be differentiated from other conditions presenting with [[hyperglycemia]], [[hyperosmolarity]] or [[Altered mental status|an altered state of consciousness]]. The differentials include [[diabetes mellitus]], [[diabetic ketoacidosis]], [[impaired glucose tolerance]], and conditions causing [[altered sensorium]] such as [[CNS infections]] or [[stroke]]. All these conditions may be differentiated on the basis of history findings, clinical features, and laboratory abnormalities.


OR
==Differentiating Hyperosmolar Hyperglycemic State From Other Diseases==
 
* Hyperosmolar hyperglycemic state must be differentiated from other diseases that present with [[hyperglycemia]], [[hyperosmolarity]], and [[altered state of consciousness]].<ref name="urlDiabetic Ketoacidosis: Evaluation and Treatment - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2013/0301/p337.html |title=Diabetic Ketoacidosis: Evaluation and Treatment - American Family Physician |format= |work= |accessdate=}}</ref><ref name="pmid19564476">{{cite journal |vauthors=Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN |title=Hyperglycemic crises in adult patients with diabetes |journal=Diabetes Care |volume=32 |issue=7 |pages=1335–43 |year=2009 |pmid=19564476 |pmc=2699725 |doi=10.2337/dc09-9032 |url=}}</ref><ref name="pmid12668546">{{cite journal |vauthors=Chiasson JL, Aris-Jilwan N, Bélanger R, Bertrand S, Beauregard H, Ekoé JM, Fournier H, Havrankova J |title=Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state |journal=CMAJ |volume=168 |issue=7 |pages=859–66 |year=2003 |pmid=12668546 |pmc=151994 |doi= |url=}}</ref><ref name="pmid18975036">{{cite journal |vauthors=Joseph F, Anderson L, Goenka N, Vora J |title=Starvation-induced true diabetic euglycemic ketoacidosis in severe depression |journal=J Gen Intern Med |volume=24 |issue=1 |pages=129–31 |year=2009 |pmid=18975036 |pmc=2607495 |doi=10.1007/s11606-008-0829-0 |url=}}</ref><ref name="pmid6361416">{{cite journal |vauthors=Williams HE |title=Alcoholic hypoglycemia and ketoacidosis |journal=Med. Clin. North Am. |volume=68 |issue=1 |pages=33–8 |year=1984 |pmid=6361416 |doi= |url=}}</ref><ref name="pmid1554971">{{cite journal |vauthors=Durnas C, Cusack BJ |title=Salicylate intoxication in the elderly. Recognition and recommendations on how to prevent it |journal=Drugs Aging |volume=2 |issue=1 |pages=20–34 |year=1992 |pmid=1554971 |doi= |url=}}</ref><ref name="pmid10970986">{{cite journal |vauthors=Gokel Y, Paydas S, Koseoglu Z, Alparslan N, Seydaoglu G |title=Comparison of blood gas and acid-base measurements in arterial and venous blood samples in patients with uremic acidosis and diabetic ketoacidosis in the emergency room |journal=Am. J. Nephrol. |volume=20 |issue=4 |pages=319–23 |year=2000 |pmid=10970986 |doi=10.1159/000013607 |url=}}</ref><ref name="pmid9587792">{{cite journal |vauthors=Brinkmann B, Fechner G, Karger B, DuChesne A |title=Ketoacidosis and lactic acidosis--frequent causes of death in chronic alcoholics? |journal=Int. J. Legal Med. |volume=111 |issue=3 |pages=115–9 |year=1998 |pmid=9587792 |doi= |url=}}</ref>
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
* Hyperosmolar hyperglycemic state should also be differentiated from conditions that can cause [[Focal neurologic signs|focal neurological signs]] or an [[Altered mental state|altered state of consciousness]] such as [[CNS infections]] and [[stroke]] by doing a simple [[Glucose test|finger stick glucose testing]].
 
{|
==Differentiating Hyperosmolar hyperglycemic state from other Diseases==
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
Hyperosmolar hyperglycemic state must be differentiated from other diseases that cause hyperglycemia, hyperosmolarity, and altered state of conciousness.<ref name="urlDiabetic Ketoacidosis: Evaluation and Treatment - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2013/0301/p337.html |title=Diabetic Ketoacidosis: Evaluation and Treatment - American Family Physician |format= |work= |accessdate=}}</ref><ref name="pmid19564476">{{cite journal |vauthors=Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN |title=Hyperglycemic crises in adult patients with diabetes |journal=Diabetes Care |volume=32 |issue=7 |pages=1335–43 |year=2009 |pmid=19564476 |pmc=2699725 |doi=10.2337/dc09-9032 |url=}}</ref><ref name="pmid12668546">{{cite journal |vauthors=Chiasson JL, Aris-Jilwan N, Bélanger R, Bertrand S, Beauregard H, Ekoé JM, Fournier H, Havrankova J |title=Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state |journal=CMAJ |volume=168 |issue=7 |pages=859–66 |year=2003 |pmid=12668546 |pmc=151994 |doi= |url=}}</ref><ref name="pmid18975036">{{cite journal |vauthors=Joseph F, Anderson L, Goenka N, Vora J |title=Starvation-induced true diabetic euglycemic ketoacidosis in severe depression |journal=J Gen Intern Med |volume=24 |issue=1 |pages=129–31 |year=2009 |pmid=18975036 |pmc=2607495 |doi=10.1007/s11606-008-0829-0 |url=}}</ref><ref name="pmid6361416">{{cite journal |vauthors=Williams HE |title=Alcoholic hypoglycemia and ketoacidosis |journal=Med. Clin. North Am. |volume=68 |issue=1 |pages=33–8 |year=1984 |pmid=6361416 |doi= |url=}}</ref><ref name="pmid1554971">{{cite journal |vauthors=Durnas C, Cusack BJ |title=Salicylate intoxication in the elderly. Recognition and recommendations on how to prevent it |journal=Drugs Aging |volume=2 |issue=1 |pages=20–34 |year=1992 |pmid=1554971 |doi= |url=}}</ref><ref name="pmid10970986">{{cite journal |vauthors=Gokel Y, Paydas S, Koseoglu Z, Alparslan N, Seydaoglu G |title=Comparison of blood gas and acid-base measurements in arterial and venous blood samples in patients with uremic acidosis and diabetic ketoacidosis in the emergency room |journal=Am. J. Nephrol. |volume=20 |issue=4 |pages=319–23 |year=2000 |pmid=10970986 |doi=13607 |url=}}</ref><ref name="pmid9587792">{{cite journal |vauthors=Brinkmann B, Fechner G, Karger B, DuChesne A |title=Ketoacidosis and lactic acidosis--frequent causes of death in chronic alcoholics? |journal=Int. J. Legal Med. |volume=111 |issue=3 |pages=115–9 |year=1998 |pmid=9587792 |doi= |url=}}</ref>
!Diseases
* '''<u>Other conditions causing hyperglycemia</u>'''
!Laboratory Findings
** [[Diabetes mellitus]]
!Physical Examination
** [[Diabetic ketoacidosis]]
!History and Symptoms
** [[Impaired glucose tolerance]]
!Other Findings
** Stress [[hyperglycemia]]
* '''<u>Other conditions causing hyperosmolarity</u>'''
** [[Central diabetes inspidus]]
** [[Primary hyperaldosteronism]]
** [[Secondary hyperaldosteronism]]
* '''<u>Other conditions causing altered state of conciousness</u>'''
** [[CNS infections]]
** [[Hypoglycemia]]
** [[Severe dehydration]]
** [[Stroke]]
** [[Hyperammonemia]]
** [[Uremia]]
 
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Characteristic Common to Hyperosmolar hyperglycemic state
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Condition
! align="center" style="background:#4479BA; color: #FFFFFF;" + |History Findings
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Clinical Features
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Lab abnormalities
|-
|-
| rowspan="3" |[[Hyperglycemia]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Diabetes mellitus]]
|[[Diabetes mellitus]]
| style="background: #F5F5F5; padding: 5px;" |
|
* [[Family history]] of [[diabetes]]
* [[Obesity]] ([[Body mass index|BMI]] >25 kg/m2)
* Stress
* [[Sedentary lifestyle]]
* History of [[gestational diabetes]]
* [[Polycystic ovary syndrome|Polycystic ovarian syndrome]]
* [[Acanthosis nigricans]]
* [[Hypertension]] ([[Blood pressure]] >140/90 mmHg)
|
* [[Polyuria]]
* [[Polydipsia]]
* [[Polyphagia]]
* [[Weight loss]]
* [[Central obesity]]
* [[Autonomic neuropathy|Autonomic]] and [[peripheral neuropathy]]
* Vascular occlusion secondary to [[atherosclerosis]] ([[Stroke]], [[myocardial infarction]])
* [[Renal impairment]] ([[microalbuminuria]] leading to [[renal failure]])
* Decreased [[visual acuity]] ([[diabetic retinopathy]])
* Increased susceptibility to [[infections]]
* [[Charcot joint|Charcot's joints]]
|
* [[Hyperglycemia]]:
* [[Hyperglycemia]]:
** [[Fasting blood sugar|Fasting blood glucose]] level: >126 mg/dl
** [[Fasting blood sugar|Fasting blood glucose]] level: >126 mg/dl
** Random [[blood]] [[glucose]] level: >200 mg/dl
** Random [[blood]] [[glucose]] level: >200 mg/dl
* [[Glycosylated hemoglobin|HbA1C]]: >6.5 %
** [[Glycosylated hemoglobin|HbA1C]]: >6.5 %
* [[Urinalysis|Urinanalysis]] may show:
* [[Urinalysis|Urinanalysis]] may show:
** [[Proteinuria]]
** [[Proteinuria]]
** [[Glucosuria]]
** [[Glucosuria]]
 
* Positive [[antibodies]]: ([[Type 1 diabetes mellitus|Type 1 diabetes]])
* Positive [[antibodies]]:(Type 1 diabetes)
** Anti-[[glutamic acid decarboxylase]]
** Anti-[[glutamic acid decarboxylase]]
** Anti-[[Islets of Langerhans|islet cell]]
** Anti-[[Islets of Langerhans|islet cell]]
** Anti-[[insulin]]
** Anti-[[insulin]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Autonomic neuropathy|Autonomic]] and [[peripheral neuropathy]]
* Decreased [[visual acuity]] ([[diabetic retinopathy]])
* [[Central obesity]][[Body mass index|(BMI]] >25 kg/m2)
* [[Hypertension]] ([[Blood pressure]] >140/90 mmHg)
| style="background: #F5F5F5; padding: 5px;" |
* [[Family history]] of [[diabetes]]
* [[Sedentary lifestyle]]
* Stress
* [[Polyuria]]
* [[Polydipsia]]
* [[Polyphagia]]
* [[Weight loss]]
| style="background: #F5F5F5; padding: 5px;" |
* History of [[gestational diabetes]]
* [[Polycystic ovary syndrome|Polycystic ovarian syndrome]]
* [[Acanthosis nigricans]]
|-
|-
|Diabetic ketoacidosis
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Diabetic ketoacidosis]]
|
| style="background: #F5F5F5; padding: 5px;" |
* Younger age with [[Diabetes mellitus type 2|type 1 diabetes mellitus]]
* Undiagnosed [[Diabetes mellitus type 2|type 1 diabetes mellitus]]
* Prolonged [[hyperglycemia]]
|
* May have all clinical features of [[diabetes mellitus]] plus:
** [[Hypotension]]
** [[Dehydration]]
** [[Tachycardia]]
**
**
|
* [[Blood]] [[pH]] < 7.3
* [[Blood]] [[pH]] < 7.3
* [[Serum]] [[bicarbonate]] < 18 mEq/L
* [[Serum]] [[bicarbonate]] < 18 mEq/L
* [[Anion gap]] > 10 mEq/L  
* [[Anion gap]] > 10 mEq/L
* Increased [[serum]] [[osmolarity]].
* Increased [[serum]] [[osmolarity]]
| style="background: #F5F5F5; padding: 5px;" |
* May have all clinical features of [[diabetes mellitus]]
* [[Hypotension]]
* [[Tachycardia]]
* [[Dehydration]]
| style="background: #F5F5F5; padding: 5px;" |
* Younger age with [[Diabetes mellitus type 2|type 1 diabetes mellitus]]
* Prolonged [[hyperglycemia]]
* Undiagnosed [[Diabetes mellitus type 2|type 1 diabetes mellitus]]
| style="background: #F5F5F5; padding: 5px;" |
|-
|-
|[[Impaired glucose tolerance]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Impaired glucose tolerance]]
|
| style="background: #F5F5F5; padding: 5px;" |
* [[Family history]] of [[Diabetes mellitus|diabetes]]
[[Hyperglycemia]]:
* [[Fasting blood sugar|Fasting blood glucose]] level: 100-125 mg/dl
* [[Oral glucose tolerance test]]: 140-200 mg/dl
| style="background: #F5F5F5; padding: 5px;" |
* May have all clinical features of [[diabetes mellitus]]
* [[Obesity]] ([[Body mass index|BMI]] >25 kg/m2)
* [[Obesity]] ([[Body mass index|BMI]] >25 kg/m2)
* Stress
| style="background: #F5F5F5; padding: 5px;" |
* [[Family history]] of [[diabetes]]
* [[Sedentary lifestyle]]
* [[Sedentary lifestyle]]
* History of [[gestational diabetes]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Acanthosis nigricans]]
|
* May have all clinical features of [[diabetes mellitus]]
|
* [[Hyperglycemia]]:
** [[Fasting blood sugar|Fasting blood glucose]] level: 100-125 mg/dl
** [[Oral glucose tolerance test]]: 140-200 mg/dl
|-
| rowspan="2" |Hyperosmolarity
|Central diabetes inspidus
|
*
|
*
|
*
|-
|Hyperaldosteronism
|
*
*
|
*
|
*
|-
| rowspan="4" |Altered state of conciousness
|CNS infections
|
*
|
*
|
*
|-
|Hypoglycemia
|
**
|
**
|
*
|-
|Stroke
|
**
|
*
|
*
|-
|Uremia
|
**
|
*
|
*
|-
|
|
|
|
|
|}
|}
Differentiating hyperosmolar hyperglycemic state from [[diabetic ketoacidosis]] (DKA) based on laboratory findings.
{| style="border: 0px; font-size: 90%; margin: 3px; width: 1000px" align="center"


===Use if the above table can not be made===
{| style="border: 0px; font-size: 90%; margin: 3px; width: 1000px" align="center"
| valign="top" |
|+
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Differential Diagnosis}}
! style="background: #4479BA; width: 200px;" | Parameters
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Similar Features}}
! style="background: #4479BA; width: 300px;" | [[Diabetic ketoacidosis (DKA)]]
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Differentiating Features}}
! style="background: #4479BA; width: 300px;" | [[Hyperosmolar hyperglycemic state (HHS)]]
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Plasma glucose
| style="padding: 5px 5px; background: #F5F5F5;" |
* > 250 mg/dl
| style="padding: 5px 5px; background: #F5F5F5;" |
* > 600 mg/dl
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 1
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Serum osmolality
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
* Variable
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
* > 320 mOsm/kg
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 2
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Plasma and urine ketones
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
* Positive
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
* None or trace
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 3
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Serum bicarbonate
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
* < 18 mEq/L
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
* > 15 mEq/ L
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 4
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Arterial ph
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
* < 7.30
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
* > 7.30
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 5
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Anion gap
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
* > 12
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
* < 12
|}
|}


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{{WH}}
{{WH}}
{{WS}}
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[[Category:Medicine]]
[[Category:Endocrinology]]
[[Category:Up-To-Date]]
​
[[Category:Emergency medicine]]

Latest revision as of 22:40, 25 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2]

Overview

The hyperosmolar hyperglycemic state must be differentiated from other conditions presenting with hyperglycemia, hyperosmolarity or an altered state of consciousness. The differentials include diabetes mellitus, diabetic ketoacidosis, impaired glucose tolerance, and conditions causing altered sensorium such as CNS infections or stroke. All these conditions may be differentiated on the basis of history findings, clinical features, and laboratory abnormalities.

Differentiating Hyperosmolar Hyperglycemic State From Other Diseases

Diseases Laboratory Findings Physical Examination History and Symptoms Other Findings
Diabetes mellitus
Diabetic ketoacidosis
Impaired glucose tolerance

Hyperglycemia:

Differentiating hyperosmolar hyperglycemic state from diabetic ketoacidosis (DKA) based on laboratory findings.

Parameters Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic state (HHS)
Plasma glucose
  • > 250 mg/dl
  • > 600 mg/dl
Serum osmolality
  • Variable
  • > 320 mOsm/kg
Plasma and urine ketones
  • Positive
  • None or trace
Serum bicarbonate
  • < 18 mEq/L
  • > 15 mEq/ L
Arterial ph
  • < 7.30
  • > 7.30
Anion gap
  • > 12
  • < 12

References

  1. ↑ "Diabetic Ketoacidosis: Evaluation and Treatment - American Family Physician".
  2. ↑ Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN (2009). "Hyperglycemic crises in adult patients with diabetes". Diabetes Care. 32 (7): 1335–43. doi:10.2337/dc09-9032. PMC 2699725. PMID 19564476.
  3. ↑ Chiasson JL, Aris-Jilwan N, Bélanger R, Bertrand S, Beauregard H, Ekoé JM, Fournier H, Havrankova J (2003). "Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state". CMAJ. 168 (7): 859–66. PMC 151994. PMID 12668546.
  4. ↑ Joseph F, Anderson L, Goenka N, Vora J (2009). "Starvation-induced true diabetic euglycemic ketoacidosis in severe depression". J Gen Intern Med. 24 (1): 129–31. doi:10.1007/s11606-008-0829-0. PMC 2607495. PMID 18975036.
  5. ↑ Williams HE (1984). "Alcoholic hypoglycemia and ketoacidosis". Med. Clin. North Am. 68 (1): 33–8. PMID 6361416.
  6. ↑ Durnas C, Cusack BJ (1992). "Salicylate intoxication in the elderly. Recognition and recommendations on how to prevent it". Drugs Aging. 2 (1): 20–34. PMID 1554971.
  7. ↑ Gokel Y, Paydas S, Koseoglu Z, Alparslan N, Seydaoglu G (2000). "Comparison of blood gas and acid-base measurements in arterial and venous blood samples in patients with uremic acidosis and diabetic ketoacidosis in the emergency room". Am. J. Nephrol. 20 (4): 319–23. doi:10.1159/000013607. PMID 10970986.
  8. ↑ Brinkmann B, Fechner G, Karger B, DuChesne A (1998). "Ketoacidosis and lactic acidosis--frequent causes of death in chronic alcoholics?". Int. J. Legal Med. 111 (3): 115–9. PMID 9587792.

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